Financial Needs Analysis Questionnaire

Expert Financial Analysis

Confidential Questionnaire

Print client names

First Name (client 1)

MI

Last Name

Birth Date

Social Insurance #

Sex

Drivers License #

Issue Date

Expiration Date

Birth Place

First Name (client 2)

MI

Last Name

Birth Date

Social Insurance #

Sex

Drivers License #

Issue Date

Expiration Date

Birth Place

Print children's names (if applicable)

Last

First

Last

First

Last

First

Last

First

* Relationship to the Client: (son, daughter, stepchild, etc.)

Mailing address and contact info

Address

MI MI MI MI

City

Sex

M F

Sex

M F

Sex

M F

Sex

M F

Relationship* Relationship* Relationship* Relationship*

Province

Postal Code

Birth Date Birth Date Birth Date Birth Date

Years at Address

Home Phone

( )

E-mail Client 1

Client 1 Work

( )

Client 2 Cell

( )

Email Client 2

Client 2 Work

( )

Client 2 Cell

( )

Enter client 1's employer (If less than 2 years, please include prior employer)

Name of Employer

Date Hired

Occupation

Address

City

Province

Postal Code

Enter client 2's employer (If less than 2 years, please include prior employer)

Name of Employer

Date Hired

Occupation

Address

City

Province

Postal Code

Previous Employers (If necessary)

Name of Company

Name of Company

Time Employed Time Employed

1..INCOME SOURCES

)

Income (pay-stub?):

Other Monthly Income:

$__________________ $__________________

$__________________ $__________________

How often are you paid?

____ Weekly ____ 2x/month ____ Biweekly ____ Monthly

Monthly Income Taxes: $__________________ $__________________

Do you normally receive an income tax refund? Yes No How much was your last tax refund? $___________________

Filename: 2014 EFA data Collection Sheet

Page 1

Revised: 2/2/2015

2. EMPLOYER SPONSORED RETIREMENT PLANS Are you currently involved in any type of retirement plan through work?

Current Total Balance

Yes No ___________

$__________

Yes No ___________

$__________

How much do you contribute monthly? Does your employer match your retirement contributions?

$__________ Yes No

$__________ Yes No

How much? $________ _____%

At What age would you like to Retire?

__________

$________ _____% __________

How much monthly income would you like to receive at retirement in today's dollars? $__________ _____% (i.e. $ or 80% of current income) Is retiring well important enough that you would commit to setting aside money every month? Yes No If I can help you retire at age _________, would you implement that plan? Yes No

3. OTHER RETIREMENT ASSETS

Do you have any other funds for retirement? (RRSP's, TFSA's or Retirement Plans from Previous Employer)

Client 1

What are the balances in these accounts? $___________

Yes No

Client 2

$___________

Monthly Contribution $___________ If we could show you a better solution for these accounts, would you be willing to move them? Yes No

$___________

4. OTHER ASSETS Do you have any other assets (real estate, jewelry, etc.)

Yes No If yes, what is the value? $__________________

______________________________________________________________________________________________________________________

5. NON-RETIREMENT ASSETS

Client 1 Balance

Client 2 Balance

Total Balance

Monthly Contributions

Bank Savings, Checking $__________

$__________

$__________

$__________

Stocks, Mutual Funds CD's, Bonds $__________

$__________

$__________

$__________

6. PROTECTION INFORMATION

Do you have a current will? Yes No If it were affordable, would you like to have one? Yes No

Other Insurance Payments Auto $__________ Health $__________ Dental $__________ Home $__________ Other $__________ Would you like to see if you could save Money on your car insurance? Yes No

Life Insurance Coverage

Do you use tobacco in any form? Is there any reason either of you would not qualify for Life Insurance? (Medical History)

Do you have any Life Insurance coverage at work? Group Coverage Amount Paid For By Employer Amount of Employee paid coverage

Client 1

Yes No Yes No Yes No $__________ $__________

Client 2

Yes No Yes No Yes No $__________ $__________

Children

Yes No

$__________ $__________

How much of the premium do you pay per month?

$__________

$__________

$__________

What happens to your group coverage if or when you leave your employer? __________ (generally, this is lost if you leave due to layoff or extended illness)

Filename: 2014 EFA data Collection Sheet

Page 2

Revised: 2/2/2015

Do you own personal life insurance other than through work? Yes No

IF NO: When people do not have life Insurance it is usually for a couple different reasons.

Did not see the need

Could not afford it

Never got around to it Other _____________________

IF YES: Do you feel that you are over-insured or underinsured, right now? Over-insured Under-insured Don't Know

What type of policy do you currently have? What is the face Amount?

What are your current monthly premiums? When did you buy it?

Why did you buy your existing plans? Protection Savings Both

Client 1

__________ $__________ $__________

__________

Client 2

__________ $__________ $__________

__________

Children

__________ $__________ $__________

__________

If you were to consider a change in benefits, what interests you most? Lower cost More protection More savings (check all that apply)

When was the last time you spoke with the agent who sold you this insurance policy? __________________________

If you were to die prematurely do you want your....

Debt paid off? Mortgage paid off? Children's education Paid? Funeral & final expenses paid?

Client 1 Yes No Yes No Yes No Yes No

Client 2 Yes No Yes No Yes No Yes No

If all of these were paid off how much monthly income would your survivors need? For how many years?

$_____________ per mo. $____________per mo. ______________years _____________ years

(If they have protection) If we put together a plan that improves your current plan, would you change if it were better?

Yes No

(If NO protection) If we put together a plan that will protect your family and it is within you budget, would you get the protection? Yes No

Are you be interested in Disability, Health and Dental, or Critical Illness Insurance Coverage? ___________________________________

______________________________________________________________________________________________________________________

7. EDUCATION DATA

Child 1

Education Cost

__________

Percentage You Intend to Pay __________%

Current Savings Balance $__________

Current Monthly Contributions $__________

Child 2

__________ __________% $__________ $__________

Child 3

__________ __________% $__________ $__________

Child 4

__________ __________% $__________ $__________

Child 5

__________ __________% $__________ $__________

Child 6

__________ __________% $__________ $__________

8. OTHER GOALS AND DREAMS Are there any major purchases that you are looking to make in the next 3-5 years? (new home, car, vacation, etc.) __________________________ ______________________________________________________________________________________________________________________ 9. MORTGAGE DATA Original Purchase Price: $__________________ Current Mortgage Balance: $__________________ Interest Rate : ________% When did you buy your home? __________ Amount of Down Payment?: $___________ How much could you sell your home for? $___________

Payment Details:

Principal & Interest Payment: Monthly Property Taxes:

Mortgage Insurance Premium Total Monthly Mortgage Payment:

$__________ (Monthly, Weekly, Biweekly) $__________ Mortgage Company: ________________________________ $__________ Renewal date:_____________________________________ $__________ *Please fill out Zero Plan forms for smoother processing

Filename: 2014 EFA data Collection Sheet

Page 3

Revised: 2/2/2015

______________________________________________________________________________________________________________________ 10. CONSUMER DEBT Do you have any debt outside your mortgage? Yes No

Debt

Balance

Min. Payment.

Actual Payment. Insurance Premium

Interest Rate

_______________________

$____________ $__________ $__________ $__________

________%

_______________________

$____________ $__________ $__________ $__________

________%

_______________________

$____________ $__________ $__________ $__________

________%

_______________________

$____________ $__________ $__________ $__________

________%

_______________________

$____________ $__________ $__________ $__________

________%

_______________________

$____________ $__________ $__________ $__________

________%

_______________________

$____________ $__________ $__________ $__________ ________%

_______________________

$____________ $__________ $__________ $__________

________%

_______________________

$____________ $__________ $__________ $__________

________%

NOTE: If car is leased, do not list as a debt ? unless planning to purchase outright.

What I'd like to do now is explore all of the possibilities to get you debt free and see which debt elimination plan is best suited for your family. That might be a debt consolidation loan through refinancing, or possibly Debt Snowball. Get authorizations on the Zero Plan application to see if we can help.

______________________________________________________________________________________________________________________

11. Experts say we should budget 10% of our monthly gross income for financial and retirement planning. 10% of your monthly income is $________

Is this an amount that you could feel comfortable setting aside each month. Yes No If no, how much of the 10% would you feel

comfortable with on a monthly basis. $100 per month $200 per month $500 per month Other $_________________

12. COMMITMENTS If when I come back and I offer you a program that could improve upon your current savings, debt situation, or insurance needs, will you implement and follow that program if it is better for you? Yes No

Last but not least, my `fee for service' is referrals and recommendations. Will you provide me with a minimum of 5 referrals if you like what I can implement for you? Yes No (Leave Referral Sheets)

EFA Follow-up Date: ______________________

Time: ______________

I/We have been advised that the Experior Financial Group Advisor is not a mortgage broker/agent and they have not discussed mortgages, or interest rates.

I authorize my representative and insurer and its authorized personnel to use the personal information contained in this document to review my financial needs on a regular basis and make appropriate recommendations. I authorize my Experior Financial Group representative to share all the above with any affiliated company required to develop and complete a comprehensive financial analysis of my situation including recommendations. The personal information you have provided in this document for the purpose of analyzing your financial needs will remain confidential. Only your representative, insurer and their authorized personnel will have access to the information in your file. Unless required by law it will be disclosed only to persons duly authorized by you. You are entitled to consult the personal information contained in this file and, if applicable, have it corrected by sending us a written request. I/We understand that Experior Financial Group may receive a referral fee from the lending institution.

Approved By: _____________________________________________________________ Approved By: _____________________________________________________________

Date: _________________________ Date: _________________________

Filename: 2014 EFA data Collection Sheet

Page 4

Revised: 2/2/2015

The greatest compliment you can give is referrals.

Client's Name: _________________ Agent's Name: _________________

WHO DO YOU KNOW?

BEST FRIEND

FAMILY

CO-WORKERS

___________________________________________________________________________________________________________________________________________________

1)

Name(s):_____________________________________________ Phone #__________________________________ Relationship________________________________

Occupation: __________________________ Age 25-55

Married

Children

Homeowner

Employed

____________________________________________________________________________________________________________________________________________________

2)

Name(s):_____________________________________________ Phone #__________________________________ Relationship________________________________

Occupation: __________________________ Age 25-55

Married

Children

Homeowner

Employed

____________________________________________________________________________________________________________________________________________________

3)

Name(s):_____________________________________________ Phone #__________________________________ Relationship________________________________

Occupation: __________________________ Age 25-55

Married

Children

Homeowner

Employed

____________________________________________________________________________________________________________________________________________________

4)

Name(s):_____________________________________________ Phone #__________________________________ Relationship________________________________

Occupation: __________________________ Age 25-55

Married

Children

Homeowner

Employed

____________________________________________________________________________________________________________________________________________________

5)

Name(s):_____________________________________________ Phone #__________________________________ Relationship________________________________

Occupation: __________________________ Age 25-55

Married

Children

Homeowner

Employed

____________________________________________________________________________________________________________________________________________________

6)

Name(s):_____________________________________________ Phone #__________________________________ Relationship________________________________

Occupation: __________________________ Age 25-55

Married

Children

Homeowner

Employed

____________________________________________________________________________________________________________________________________________________

7)

Name(s):_____________________________________________ Phone #__________________________________ Relationship________________________________

Occupation: __________________________ Age 25-55

Married

Children

Homeowner

Employed

____________________________________________________________________________________________________________________________________________________

8)

Name(s):_____________________________________________ Phone #__________________________________ Relationship________________________________

Occupation: __________________________ Age 25-55

Married

Children

Homeowner

Employed

____________________________________________________________________________________________________________________________________________________

9)

Name(s):_____________________________________________ Phone #__________________________________ Relationship________________________________

Occupation: __________________________ Age 25-55

Married

Children

Homeowner

Employed

____________________________________________________________________________________________________________________________________________________

10)

Name(s):_____________________________________________ Phone #__________________________________ Relationship________________________________

Occupation: __________________________ Age 25-55

Married

Children

Homeowner

Employed

____________________________________________________________________________________________________________________________________________________

Filename: 2014 EFA data Collection Sheet

Page 5

Revised: 2/2/2015

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